Low dose estrogen interrupted hormone replacement therapy

ABSTRACT

A hormone replacement therapy, comprising a plurality of daily doses of a pharmaceutical preparation, the doses being administered continuously and consecutively in alternating phases of three daily doses, a relatively dominant estrogenic activity phase comprising three daily doses of a substance exhibiting estrogenic activity equivalent to about 1 mg per day of 17β-estradiol per day, and a relatively dominant progestagenic activity phase of a combination of a substance exhibiting estrogenic activity equivalent to about 1 mg per day of 17β-estradiol and a substance exhibiting progestogenic activity equivalent to about 90 μg per day of norgestimate.

RELATED APPLICATIONS

This application is a continuation of application Ser. No. 09/538,485,filed Mar. 30, 2000, now abandoned.

This application claims the benefit of priority from U.S. ProvisionalApplication No. 60/126,970 filed Mar. 30, 1999, the disclosure of whichis incorporated herein by reference.

FIELD OF THE INVENTION

The present invention relates to hormone replacement therapy (HRT) foradministration to menopausal or castrate women. More specifically, thepresent invention relates to a hormone replacement therapy regimencomprising a specific dosage combination that includes a reduced amountof estrogen, which provides a reduced risk of cancer, while providing aregimen with vasomotor symptom relief that is usually only available athigher estrogen levels.

BACKGROUND OF THE INVENTION

Background Art

There are a number of patents relating to hormone replacement therapyand many different formulations available in the marketplace. Manyformulations involve the administration of continuous estrogen andprogestogen, while other regimens can be characterized as interrupted orcyclophasic. Examples of patents covering interrupted regimens includeRobert F. Casper's U.S. Pat. No. 5,108,995 issued Aug. 28, 1992, for amethod of HRT; U.S. Pat. No. 5,256,421 issued Oct. 26, 1993 for an HRTmethod; U.S. Pat. No. 5,422,119 issued Jun. 6, 1995 for a transdermalHRT method, preparation and package; and U.S. Pat. No. 5,382,573 issuedJan. 17, 1995, which relates to an HRT preparation and package. Casperis also the holder of U.S. Pat. No. 5,276,022 issued Jan. 4, 1994 andU.S. Pat. No. 593,585,370 issued Dec. 17, 1996 both of which relate tocontraceptive therapy. The disclosures of all of these patents areincorporated herein by reference.

The Casper hormone replacement therapy (HRT) and hence the cyclophasicregimens disclosed by Casper seek to induce higher levels of progestogenand estrogen receptors by an estrogen-induced increase in receptorproduction. The greater concentration of steroid receptors increases thesensitivity of the target organs to progestogen and estrogen and allowsthe use of lower doses of exogenous steroids. The cyclophasic orinterrupted regimens of Casper upregulate the estrogen and progestogenreceptors in an estrogen-dominant phase and then down-regulate the samereceptors in a progestogen-dominant phase. In both phases of the Casperregimen, the estrogen dose is constant while the progestogen dose isvaried to produce relatively progestogen-dominant or estrogen-dominanteffects. These alternating phases continue without interruption in theCasper HRT regimen.

Hot flashes or flushes occur in about 75 percent of menopausal women.The flushes may begin in the perimenopausal period when relativeestrogen deficiency occurs together with cycle irregularity secondary toanovulation, but they usually begin during or after the menopause. Hotflushes typically begin as a sudden sensation of heat centered on theface and upper chest that rapidly becomes generalized. The sensation ofheat lasts between two and four minutes, is frequently associated withprofuse perspiration and occasionally palpitations, and is oftenfollowed by chills and shivering [Casper, R F, Yen, S S C.Neuroendocrinology of menopausal flushes: An hypothesis offlushmechanism. Clin Endocrinol 1985; 22:293].

Hot flushes usually occur several times per day, although the range maybe from only one or two each day to as many as one per hour during theday and night. Flushes cause arousal from sleep, leading to sleepdisturbances. In addition, many women have profuse perspiration, whichcan be embarrassing in social situations.

The cause of hot flushes is unknown. They are thought to be due tothermoregulatory dysfunction, initiated at the level of the hypothalamusby estrogen withdrawal [ibid.]. Evidence for central mediation of thechanges in temperature comes from studies demonstrating that hot flushesoccur simultaneously with pulses of luteinizing hormone [Casper, R F,Yen, S S C, Wilkes, M M. Menopausal flushes: A neuroendocrine link withpulsatile luteinizing hormone secretion. Science 1979; 205:823 andTataryn, I V, Meldrum, D R, Lu, K H, et al. L H, FSH and skintemperature during the menopausal hot flash. J Clin Endocrinol Metab1979; 49:152].

A speculative mechanism for the initiation of hot flushes is endogenousopioid peptide withdrawal. Estrogen increases central opioid peptideactivity, while menopause appears to be associated with decreased orabsent endogenous central opioid activity [Reid, R L, Quigley, M E, Yen,S S. The disappearance of opiodidergic regulation of gonadotropinsecretion in postmenopausal women. J Clin Endocrinol Metab 1983;57:1107].

Whatever the cause of hot flushes, the most effective way known toprevent or treat them in women with estrogen deficiency is to administerestrogen.

In women who have not had a hysterectomy, estrogen should always begiven in combination with a progestogen, to prevent the occurrence ofendometrial hyperplasia and associated malignancies of the endometrium.Estrogen-progestogen therapy also is more effective than estrogen alonein ameliorating hot flushes, possibly because progestogen also increasescentral opioid peptide activity [Casper, R F, Alapin-Rubillowicz, S J.Progestogen increases endogenous opioidpeptide activity inpostmenopausal women. J Clin Endocrinol Metab 1985; 60:34].

Progestogen administration alone can inhibit gonadotropin secretion,increase hypothalamic endogenous opioid peptide activity [Casper, R F,Alapin-Rubillowicz, S J. Progestogen increases endogenous opioid peptideactivity in postmenopausal women. J Clin Endocrinol Metab 1985; 60:34],and ameliorate hot flashes Schiff, I. The effects of progestogens onvasomotor flushes. J Reprod Med 1982; 27(Suppl):498]. As an example,megestrol acetate (at a dose of 20 to 80 mg/day) decreases the frequencyof hot flushes by 85 percent (versus 21 percent with placebo) [Loprinzi,C L, Michalak, J C, Quella, S K, et al. Megestrol acetate for theprevention of hotflashes. N Engl J Med 1994; 331:347]. Otherprogestogens such as norethindrone acetate (10 mg daily) are alsoeffective.

The bothersome symptoms of hot flushes are the most frequent reason forwomen to seek hormone replacement therapy. The improvement in hotflushes leads to long term utilization of hormone replacement therapywith many additional benefits of such use including a 50% reduction inheart disease, prevention of osteoporosis, and perhaps, as new evidenceindicates, prevention of Alzheimer's disease. At the present time, themajor controversial area concerning the risks of hormone replacementtherapy involves breast cancer. It is believed, but not proven, that therisk of breast cancer in women taking hormone replacement therapy isrelated to the dose of estrogen exposure over time.

Despite substantial efforts made to date, there remains a need forimproved HRT regimens that minimize estrogen exposure, while effectivelyrelieving symptoms such as hot flushes.

SUMMARY OF THE INVENTION

It has now been discovered that a selected dosage regimen within thebroad class proposed in the aforementioned US Patents, providesunexpected benefits that are of major significance for the patient.

The remarkable finding of the regimen is that maximum symptom relief, inparticular hot flushes, is obtained with the regimen and this relief isequivalent to that for a regimen of the same type where the estrogenlevel is 100 percent higher. It was unexpected that symptom relief wouldbe the same for both estrogen levels in this type of regimen.

The advantage of the present regimen over those of the same class withhigher estrogen levels is that it offers an increased margin of safetybecause of its lower estrogen level, while providing the same symptomrelief.

The regimen of the present invention was also compared with a known HRTregimen sold under the brand names KLIOGEST® and KLIOSEM® and known forits effective symptom relief. This known product contains 100 percenthigher estrogen than the present formulation. Symptom relief wasequivalent in both regimens.

The present invention provides, in one aspect, a pharmaceuticalpreparation for administration to a female in need of hormonereplacement therapy, comprising a plurality of doses for consecutiveadministration in alternating phases, the phases consisting of arelatively dominant estrogenic activity phase comprising three dailydoses or an equivalent thereof, of a substance exhibiting estrogenicactivity equivalent to about 1 mg per day of 17β-estradiol, and arelatively dominant progestogenic activity phase comprising three dailydoses or an equivalent thereof, of a combination of a substanceexhibiting estrogenic activity equivalent to about 1 mg per day of17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.

In a more preferred form of the pharmaceutical preparation of theinvention, there is provided a pharmaceutical preparation foradministration to a female in need of hormone replacement therapycomprising a plurality of daily doses for consecutive administration,the doses being administered consecutively in alternating phases, thephases comprising a relatively dominant estrogenic activity phasecomprising three consecutive daily doses of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradiol,and a relatively dominant progestogenic activity phase comprising threeconsecutive daily doses of a combination of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradioland a substance exhibiting progestogenic activity equivalent to about 90μg per day of norgestimate.

In another aspect of the invention, there is provided a packagecontaining a pharmaceutical preparation for administration to a femalein need of hormone replacement therapy, comprising a plurality of dosesfor consecutive administration arranged in alternating phases, thephases consisting of a relatively dominant estrogenic activity phasecomprising three daily doses or an equivalent thereof, of a substanceexhibiting estrogenic activity equivalent to about 1 mg per day of17β-estradiol, and a relatively dominant progestogenic activity phasecomprising three daily doses or an equivalent thereof, of a combinationof a substance exhibiting estrogenic activity equivalent to about 1 mgper day of 17β-estradiol and a substance exhibiting progestogenicactivity equivalent to about 90 μg per day of norgestimate.

In a more preferred form of the pharmaceutical package of the invention,there is provided a pharmaceutical package containing a pharmaceuticalregimen for administration to a female in need of hormone replacementtherapy, the doses being arranged for consecutive administration inalternating phases, the phases consisting of a relatively dominantestrogenic activity phase comprising three consecutive daily doses of asubstance exhibiting estrogenic activity equivalent to about 1 mg perday of 17β-estradiol, and a relatively dominant progestogenic activityphase comprising three consecutive daily doses of a combination of asubstance exhibiting estrogenic activity equivalent to about 1 mg perday of 17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.

In yet another aspect the invention provides a method of treating afemale in need of hormone replacement therapy comprising administeringto said female a pharmaceutical regimen comprising a plurality of dosesarranged in alternating phases, the phases comprising a relativelydominant estrogenic activity phase comprising three daily doses or anequivalent thereof, of a substance exhibiting estrogenic activityequivalent to about 1 mg per day of 17β-estradiol, and a relativelydominant progestogenic activity phase comprising three daily doses or anequivalent thereof, of a combination of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradioland a substance exhibiting progestogenic activity equivalent to about 90μg per day of norgestimate.

In yet another aspect the invention provides a use of an estrogenicallyactive substance and a progestogenically active substance in thepreparation of a medicament, characterized in that the medicament is forhormone replacement therapy for administration to a female in need ofsuch therapy, the medicament comprising a plurality of doses forconsecutive administration in alternating phases the phases consistingof a relatively dominant estrogenic activity phase comprising threedaily doses or an equivalent thereof, of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradiol,and a relatively dominant progestogenic activity phase comprising threedaily doses or an equivalent thereof, of a combination of a substanceexhibiting estrogenic activity equivalent to about 1 mg per day of17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.

In a preferred form of the invention there is provided a use of anestrogenically active substance and a progestogenically active substancein the preparation of a medicament, characterized in that the medicamentis for hormone replacement therapy for administration to a female inneed of such therapy, the medicament comprising a plurality of dailydoses for consecutive administration in alternating phases, the phasesconsisting of a relatively dominant estrogenic activity phase comprisingthree consecutive daily doses of a substance exhibiting estrogenicactivity equivalent to about 1 mg per day of 17β-estradiol, and arelatively dominant progestogenic activity phase comprising threeconsecutive daily doses of a combination of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradioland a substance exhibiting progestogenic activity equivalent to about 90μg per day of norgestimate.

DETAILED DESCRIPTION OF THE INVENTION

In a preferred form of all aspects of the invention, the substanceexhibiting progestogenic activity is selected on the basis that it bindsto progestin receptors, demonstrates poor affinity for androgenreceptors and has a lack of affinity for sex-hormone-binding globulin(SHBG).

In its most preferred form, the invention provides a therapy or regimenin which the three daily doses in the relatively dominant estrogenicactivity phase comprise about 1 mg per day of 17β-estradiol, and in therelatively dominant progestogenic activity phase comprise about 1 mg perday of 17β-estradiol and about 90 μg per day of norgestimate.

Generally the formulation of the invention will consist of a single oraltablet taken once daily. On days one through three of therapy, thetablet contains 17β-estradiol. On days four through six of therapy, thetablet contains both 1.0 mg. 17β-estradiol and 90 μg or 0.09 mg ofnorgestimate. This unique regimen consisting of a pattern of three daysof 17β-estradiol only followed by three days of 17β-estradiol plusnorgestimate is repeated continuously throughout therapy.

DEFINITIONS

A Female in Need of Hormone Replacement Therapy

Generally this would include a female of child bearing age or older inwhom ovarian estrogen and progesterone production has been interruptedeither because of natural menopause, surgical, radiation, or chemicalovarian ablation or extirpation or premature ovarian failure.

A Relatively Dominant Estrogenic Activity Phase

A Relatively Dominant Progestogenic Activity Phase

One may start the regimen with either phase, although the relativelydominant estrogenic activity phase is the preferred starting phase.

The word relative defines the activity of a phase with respect to anyimmediately preceding phase and any immediately following phase.

The only activity of the phase is the estrogenic activity and thereforeit is dominant in this phase, and this activity is relative to the otherestrogenic activity of the phase where a progestogenically activesubstance is present also. In the relatively dominant progestogenicactivity phase the dominant hormone activity is the progestogenicactivity, and again this activity in this phase is dominant relative toits activity in the other phase.

In the relatively dominant estrogenic activity phase, the estrogenstimulates endometrial growth and progestogen receptors. Consequently,the endometrium is more sensitive to subsequent progestogen activitythat limits growth by decreasing estrogen receptors and increasing17β-hydroxysteroid dehydrogenase. Interaction of progestogen in thesecond relatively dominant estrogenic activity phase with progestogenreceptors induces secretory changes in the endometrium, which results ina denser stroma and endometrial stability. A return to relativelydominant estrogenic activity then again stimulates estrogen andprogestogen receptors and renews endometrial sensitivity to progestogen.This push/pull activity keeps endometrial activity within a low rangedepending on the number of days of estrogenic and progestogenic activity[see Cameron, Sharon T., et al, Continuous transdermal oestrogen andinterrupted progestogen as a novel bleed-free regimen of hormonereplacement therapy for postmenopausal women, British Journal ofObstetrics and Gynaecology, October 1997, Vol. 104, pp. 1184-1190]. Inthis instance, the relatively dominant estrogenic activity phase lengthsthat have been found to maximize this push/pull activity are three daysfor each relatively dominant estrogenic activity phase.

A Substance Exhibiting Estrogenic Activity and a Substance ExhibitingProgestogenic Activity

Any substance that exhibits appropriate estrogenic activity may be usedin the present invention. As indicated the preferred estrogen is17β-estradiol. Other suitable estrogens include 17α-ethinylestradiol,esters and ethers of 17α-ethinylestradiol such as, for example,17α-ethinylestradiol 3-dimethylamino propionate, 17α-ethinylestradiol3-cyclopentyl ether (quienestrol) and 17α-ethinylestradiol 3-methylether (mestranol). Natural estrogens such as estrone, estrone sulfate,estrone sulfate piperazine salt, estradiol and estriol, and theiresters, as well as the synthetic estrogens, may also be employed. Theselection of the estrogen and the dose level will generally follow fromthe literature, which is well known to the person skilled in the art.The dose level is dependent on the cyclophasic regimen. The discussionthat follows about the selection of a progestogen and its dose level maybe used as a guide in the selection of the estrogen.

The preferred progestogen is norgestimate. Norgestimate is also knownunder its chemical name D-17β-acetoxy-β-ethyl-17α-ethinyl-gon-4-en-3-oneoxime. While other progestogens may be used in place of norgestimate, inselecting a suitable progestogen, and in particular norgestimate,selection criteria include degree of affinity for progestogen receptor,absence of affinity for androgen receptor and whether the progestogendisplaced androgen from human sex-hormone-binding globulin (SHBG) [seePhillips, Audrey et al., Preclinical evaluation of norgestimate, aprogestin with minimal androgenic activity, Am J Obstet Gynecology,October 1992, October 1992, Volume 167, Number 4, Part 2, pp.1191-1196]. In the case of norgestimate, it binds to progestinreceptors, it demonstrates very poor affinity for androgen receptors andit has a lack of affinity for SHBG. All of these effects make it similarto natural progesterone.

Other progestogens may be employed in the present therapy regimen aslong as they meet the criteria set forth above for the selection ofnorgestimate. In essence, the progestogen must have a profile that issimilar to norgestimate. Possible choices of those progestogens thatmeet these requirements include desogestrel, dydrogesterone,medroxyprogesterone acetate, norethynodrel, cyproterone acetate,chlormadinone acetate, magestrol acetate, 17 D-acetyl norgestimate,dienogest, trimegestone, drosperinone and nomagestrel. Examples ofprogestogens that do not have a suitable profile include norethindroneand norgestrel. The literature contains descriptions of numerousprogestogens and based on the criteria set out above, the person skilledin the art may make a suitable choice.

As stated the preferred dose for norgestimate is about 90 μg. Equivalentdoses for other progestogens may be determined by the person skilled inthe art by reference to the literature, for example the standard textTreatment of the Menopausal Woman, Basic and Clinical Aspects, Ed. Lobo,Rogerio A., Raven Press, New York, pp73-80. Dosage selection is madewith reference to hormone potency and the nature of the regimen, whichis cyclophasic and does allow for lower levels of hormones. Examples ofsuitable equivalent doses include about 54 μg/day of desogestrel, about180 μg/day of 3-keto-desogestrel, about 90 μ/day of 17D-acetylnorgestimate, about 180 μg/day of cyproterone acetate, about 720 μg/dayof dienogest, about 1080 μg/day of drosperinone and about 27 μg/day ofgestogen. When making a choice of dose level, it would be a matter ofroutine experimentation for the person skilled in the art to take theequivalent dose level in the selected hormone and then to test a fewdoses around that level in order to refine the dose level.

Three Daily Doses or an Equivalent Thereof

The daily doses of the present invention may be administered in anyconvenient form. Preferred, as set out earlier is a single daily tablet,but any other suitable form may be employed. The single tablet ispreferred as it reduces the likelihood that the patient will getconfused. The words “an equivalent thereof” are meant to coveradministrative forms that do not comprise daily doses, for example atransdermal form.

Generally speaking, the formulations are prepared according toconventionally known procedures in accordance with the desired method ofadministration. Different amounts of the active ingredients may berequired in different types of formulations but it is essential that theamount of estrogenically active substance and progestationally activesubstance be selected so as to provide the dose equivalency for theregimen as described above. The percentage of active ingredients mayvary according to the potency of the hormone, the delivery system ormethod of administration and is chosen in accordance with conventionalmethods known in the art.

The estrogen and progestogen compositions can be administered by way ofany art recognized means as practiced in the pharmaceutical arts. Forexample, the estrogen and progestogen alone or in combination may be soformulated so that it can be administered orally, via a skin patch fortransdermal absorption, by intramuscular injection, contained within aninert matrix which is implanted within the body and in a depot state, orintravaginally in a matrix that slowly releases the active compositions(such implants are taught for example in U.S. Pat. Nos. 4,957,119 and5,088,505).

Pharmaceutical compositions containing compounds of the invention mayfurther comprise pharmaceutically acceptable carriers and be in eithersolid or liquid form. Solid preparations include powders, tablets,dispersible granules, capsules, etc. The carrier may also be one or moresubstances, which act as diluents, flavoring agents, solubilizers,lubricants, suspending agents, binders, or tablet disintegrating agentsas well as encapsulating materials. Suitable carriers include magnesiumcarbonate, magnesium stearate, talc, lactose, sugar, peptin, dextrin,starch, methylcellulose, sodium carboxylmethylcellulose, and the like.Liquid form preparations include solutions, which are suitable for oralor parenteral administration, or suspensions and emulsions suitable fororal administration.

Sterile water solutions of the active component or sterile solutions ofthe active components in solvents comprising water, ethanol, orpropylene glycol are examples of liquid preparations suitable forparenteral administration. Aqueous solutions for oral administration canbe prepared by dissolving the active compound in water and addingsuitable flavorants, coloring agents, stabilizers and thickening agentsas required. Aqueous suspensions for oral use can be made by dispersingthe active component in water together with a viscous material such as anatural or synthetic gum, methylcellulose, sodiumcarboxymethyl-cellulose, and other suspending agents known to thepharmaceutical formulation art. Other solid dosage forms include topicaldosage forms which include solutions, powders, fluid emulsions, fluidsuspensions, semi-solids, ointments, pastes, creams, gels or jellies andfoams; and parenteral dosage forms which include solutions, suspensions,emulsions or dry powder comprising an effective amount of estrogen orestrogen and progestogen as taught in this invention.

Various conventional techniques for preparing pharmaceuticalcompositions including solutions, suspensions, tablets or caplets can beemployed, as would be known to those skilled in the art and as isdisclosed for example by Remington's Pharmaceutical Sciences, MackPublishing Co., Part 8, Chapters 76-93, Pharmaceutical Preparations andTheir Manufacture, pp. 1409-1677 (1985).

The pharmaceutical formulations may be provided in kit form containingpreferably multiples of three unit dosages, each constituting arelatively dominant estrogenic activity phase and in a suitable form,for example, caplets or tablets. The kit may comprise a dial package ora foil strip as is well known in the art. The kit would typicallycontain an even number of doses for each phase arranged in an evennumber of relatively dominant estrogenic activity phases. Thus the unitdosages would be arranged in each package in multiples of six so that aneven number of phases would be present in each package.

The term “unit dosage form” as used herein refers to physically discreteunits suitable as unit dosages, each unit containing a predeterminedquantity of active ingredient calculated to produce the desiredtherapeutic effect in association with the required pharmaceuticalcarrier. The term “doses” as used herein broadly encompasses the termunit dosage form or dosage units as well as continuous dosing ofcompositions by depot or other methods.

A Combined Preparation

This term is meant to indicate that the therapy or formulation is meantto comprise both an estrogenically active substance and aprogestogenically active substance. Only the relatively dominantprogestogenic activity phase involves both substances delivered incombination.

Consecutively

Generally hormone replacement therapy is administered on a daily basis,every day to a patient. This is the case in the present invention, butthere may be instances where hormone free days could be desirable. Insuch a case, dosages containing placebo or any other hormone-free agentmay be included in the regimen. Examples of suitable alternativehormone-free agents include vitamins and/or iron supplements. It shouldbe noted that the phases are consecutively administered to the patient.

The active ingredients are usually compounded with the chosen carrierand in for example the case of a tablet form, placed in a tablet moldingapparatus to form the tablets which are subsequently packaged inaccordance with the chosen regimen.

In the oral form of the formulation, the package would have the dailydosages arranged for proper sequential administration. Data indicationsmay be provided on the packaging. The packaging may be a tube or box ora strip. The box may be circular, square, or otherwise shaped with thetablets for example being accommodated separately therein for ease ofadministration. Date indications may appear adjacent each tabletcorresponding with the days on which each tablet is to be taken. Someindication of the sequence in which the tablets are to be takenpreferably appears on the packaging regardless of its form.

The invention will now be illustrated by an exemplary study involvingthe method of the invention. The examples are not intended to belimiting of the scope of the present invention. They are to be read inconjunction with the detailed and general description above, to providefurther understanding of the invention and to outline a protocol forcarrying out the methods of the invention for HRT in climacteric,perimenopausal and postmenopausal women.

EXAMPLE

In a randomized parallel group multi-center study performed by the R. W.Johnson Pharmaceutical Research Institute, three different hormonalreplacement regimens were compared with respect to effects on menopausalsymptoms, on bleeding patterns and on lipid and carbohydrate metabolism.A major endpoint in terms of menopausal symptoms and subsequent patientacceptance of treatment was the effectiveness of each regimen inalleviating hot flushes.

In the multicenter trial, the regimen of the present invention(containing 1 mg of estradiol and 90 μg of norgestimate) was comparedwith another interrupted progestogen regimen that is derived from thepreviously referenced Casper U.S. patents, and contained 2 mg ofestradiol and 180 μg of norgestimate) and to a reference preparationcontaining 2 mg of estradiol and 1 mg of norethindrone acetate, which iscurrently marketed in Europe under the trademark KLIOGEST® or KLIOSEM®.Subjects in the study recorded the number of hot flushes per day(24-hour period) on a diary card. During the pretreatment relativelydominant estrogenic activity phase, the diary had to be completed for aminimum of 5 days in order to obtain a baseline number of hot flushesfor evaluation. The subjects then received the various hormonereplacement therapies for 12 months and during treatment recorded theirhot flushes on the diary cards every day. For evaluation of this study,information on hot flushes recorded during the 30 days preceding the endof the study was compared with baseline to determine improvement in hotflushes as a result of treatment. Percent change from baseline to thelast 30 days was calculated for 182 subjects receiving the presentinvention compared to 186 subjects receiving the 2 mg estradiolinterrupted progestogen regimen and 188 subjects receiving the referencepreparation containing 2 mg of estradiol. At 12 months, all 3 regimensshowed greater than 90% reduction in the frequency of hot flushes perday. Table 1 demonstrates hot flushes from this 12-month comparativestudy.

TABLE 1 Vasomotor Symptoms from 12-month Comparative Study Low DosageHigh Dosage (CP-L) Estrogen (CP-H) Regimen of the Estrogen Kliogest ®Present Regimen HRT Invention 2 mg E₂/ Regimen 1 mg E₂/90 μg 180 μg 2 mgE₂/1 NGM NGM mg NETA Mean (SD) % decrease in −94.9 (16.2) −92.5 (22.8)−92.8 no. of HF/day from (30.0) baseline to final visit % subjectswithout HF  73.6  82.7  72.4 during Month 12 Median no. days to day  14 13  11 without HF (Kaplan- Meier Estimates)

In Table 1, HF stands for Hot Flushes or Flashes, CP-L is the lowestrogen dose of the present invention, CP-H is a 2 mg. estrogen doseregimen against which the present invention was compared. The regimen isidentical to the regimen of the present invention except for theestrogen and progestogen level. E₂ is 17β-estradiol, NGM isnorgestimate, and NETA is norethindrone acetate.

The present invention—the low dose estrogen regimen resulted in a meandecrease in the number of hot flushes per day of 94.9% compared tobaseline. The reference or Kliogest® regimen containing 2 mg ofestradiol reduced hot flushes by a mean of 92.8% and the 2 mginterrupted progestogen preparation reduced hot flushes by 92.5%. Theseresults reveal that symptom alleviation for all regimens is more or lessclinically equivalent, within reasonable statistical limits. However, itshould be noted that at the lower levels of estrogen found in theregimen of the invention, the margin of safety of the preparation isthought to be markedly increased because of the reduced risk of breastcancer.

BRIEF SUMMARY OF THE DRAWINGS

In the accompanying drawings, which are used to illustrate the presentinvention,

FIG. 1 is a graphical representation that plots % subjects without hotflushes by month.

DETAILED DESCRIPTION OF THE DRAWING

In FIG. 1, the terms and associated symbols have the following meanings:

CP-L: Low Dose Regimen of the Present Invention

CP-H: High Dose Regimen of the Present Invention

Reference: Preparation sold under the Registered TradeMark Kliogest

Baseline (BL) data recorded during the last 30 days precedingrandomization

In the Following Table 2 there are listed the number of subjects permonth recorded during the last thirty days preceding randomization. Thisdata represents the underlying data for the graphical results shown inFIG. 1.

TABLE 2 Month 1 2 3 4 5 6 7 8 9 10 11 12 13 Prep's Number of SubjectsCP-L 20 220 21 20 19 19 19 192 18 181 178 177 178 7 7 5 9 4 3 2 CP-H 20218 20 19 16 14 13 133 12 118 117 114 110 3 9 0 9 7 5 3 REF 20 216 20 2020 19 19 192 18 189 188 187 185 2 9 6 0 4 3 7

FIG. 1 shows the proportion of subjects with no hot flushes by month. Itcan be seen that there is an equal reduction in flushes by month 12between the present invention containing 1 mg of estradiol and thereference preparation containing 2 mg of estradiol. The presentinvention did take a median of 3 days longer to reach the day withouthot flushes compared to the reference preparation containing 2 mg ofestradiol and one day longer compared to the 2 mg estradiol interruptedprogestogen regimen.

These results are surprising since as described above, hot flushes areknown to occur as a result of estrogen deficiency and estrogenreplacement is the most effective treatment for preventing or improvinghot flushes. In addition, it is known that progestogen administrationalone is also capable of improving hot flushes [Schiff, I. The effectsof progestogens on vasomotor flushes. J Reprod Med 1982; 27(Suppl):498and Loprinzi, C L, Michalak, J C, Quella, S K, et al. Megestrol acetatefor the prevention of hot flushes. N Engl J Med 1994; 331:347].

It is anticipated that a synergistic effect between the combination ofestrogen and progestogen should occur to reduce hot flushes more thanestrogen replacement alone. The present invention contains half as muchestrogen as the two other regimens tested and at least half theprogestogen. The fact that the regimen of the present invention improveshot flushes to the same degree as the other two preparations containingat least twice as much estrogen is, therefore, unexpected andsurprising.

The regimen of the present invention appears to enhance effectivelyestrogenic activity in some specific estrogen target tissues, such asthe brain, in the case of hot flushes. This additional estrogenic effectof the present invention is supported by the observation that twoestrogen-induced lipoproteins, HDL, and HDL-2, thought to be the majorprotective lipoproteins against coronary heart disease, are increased tothe same extent by the 1 mg estradiol containing regimen of the presentinvention and the 2 mg estradiol containing interrupted progestogenregimen. Both regimens were superior to the reference preparationKliogest® containing 2 mg of estradiol and 1 mg norethinedrone acetate.Since elevation in HDL-2 is thought to be an estrogen dependent effect,the fact that the same level of elevation is achieved with 1 mg ofestradiol in the present invention compared to 2 mg of estradiol in asimilar interrupted progestogen preparation is consistent with anunexpected estrogenic response.

The clinical relevance of the main observation relating to the vasomotorsymptoms is important because the majority of women experience hotflushes at the time of menopause, and the bothersome symptoms of hotflushes are the most frequent reason for women to seek hormonereplacement therapy. The improvement in hot flushes leads to long termutilization of hormone replacement therapy with many additional benefitsof such use including a 50% reduction in heart disease, prevention ofosteoporosis, and perhaps, as new evidence indicates, prevention ofAlzheimer's disease. At the present time, the major controversial areaconcerning the risks of hormone replacement therapy involves breastcancer. It is believed, but not proven, that the risk of breast cancerin women taking hormone replacement therapy is related to the dose ofestrogen exposure over time. The interrupted progestogen regimen used inthe present invention is not likely to enhance estrogenic effects in thebreast, since progestogen does not down-regulate estrogen andprogestogen receptors in breast tissue (See Clarke, Christine L. andSutherland, Robert L., Progestin Regulation of Cellular Proliferation,Endocrine Reviews, Vol. 11, 1990, No. 2, pp. 266-300).

Therefore, the receptor fluctuations, which are involved in themechanism of action of the present invention, will not occur in thebreast, and a straightforward linear estrogen effect should prevail. Asa result, the present invention containing half the dose of estrogen ascompared to the other two preparations containing the 2 mg of estrogenshould result in an improved margin of safety with respect to breastcancer incidence while providing equivalent improvement in hot flushesseen in higher dose estrogen regimens.

While the invention has been described with particular reference tocertain embodiments thereof, it will be understood that changes andmodifications may be made by those of ordinary skill in the art withinthe scope and spirit of the following claims.

In the claims, the word “comprising” means “including the followingelements (in the body), but not excluding others”; the phrase“consisting of” means “excluding more than traces of other than therecited ingredients”; and the phrase “consisting essentially of” means“excluding unspecified ingredients which materially affect the basiccharacteristics of the composition”.

We claim:
 1. A pharmaceutical preparation for administration to a femalein need of hormone replacement therapy, comprising a plurality of dosesfor administration in alternating relatively dominant estrogenicactivity phases, the relatively dominant estrogenic activity phasesconsisting of a relatively dominant estrogenic activity relativelydominant estrogenic activity phase comprising three consecutive dailydoses or an equivalent thereof, of a substance exhibiting estrogenicactivity equivalent to about 1 mg per day of 17β-estradiol, and arelatively dominant progestogenic activity phase comprising threeconsecutive daily doses or an equivalent thereof, of a combination of asubstance exhibiting estrogenic activity equivalent to about 1 mg perday of 17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.
 2. The pharmaceuticalpreparation as claimed in claim 1 for administration to a female in needof hormone replacement therapy comprising a plurality of daily doses forconsecutive administration, the doses being administered in alternatingphases, the phases comprising a relatively dominant estrogenic activityphase comprising three consecutive daily doses of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradiol,and a relatively dominant progestogenic activity phase comprising threeconsecutive daily doses of a combination of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradioland a substance exhibiting progestogenic activity equivalent to about 90μg per day of norgestimate.
 3. The pharmaceutical preparation as claimedin claim 2 wherein the substance exhibiting progestogenic activity isselected on the basis that it binds to progestin receptors, demonstratespoor affinity for androgen receptors and has a lack of affinity forsex-hormone-binding globulin.
 4. The pharmaceutical preparation asclaimed in claim 3 wherein the substance exhibiting estrogenic activityis selected from 17α-ethinylestradiol, esters and ethers of17α-ethinylestradiol, 17α-ethinylestradiol 3-dimethylamino propionate,17αethinylestradiol 3-cyclopentyl ether (quienestrol) and17α-ethinylestradiol 3-methyl ether (mestranol); natural estrogens,estrone, estrone sulfate, estrone sulfate piperazine salt, estradiol andestriol, and their esters, as well as the synthetic estrogens, and thesubstance exhibiting progestogenic activity is selected fromdesogestrel, dydrogesterone, medroxyprogesterone acetate, norethynodrel,cyproterone acetate, chlormadinone acetate, magestrol acetate, 17D-acetyl norgestimate, dienogest, trimegestone, drosperinone andnomagestrel.
 5. The pharmaceutical preparation as claimed in claim 1wherein the doses are in oral form.
 6. The pharmaceutical preparation asclaimed in claim 5 wherein the oral form is a tablet.
 7. A packagecontaining a pharmaceutical preparation for administration to a femalein need of hormone replacement therapy, comprising a plurality of dosesarranged in alternating phases, the phases consisting of a relativelydominant estrogenic activity phase comprising three consecutive dailydoses or an equivalent thereof, of a substance exhibiting estrogenicactivity equivalent to about 1 mg per day of 17β-estradiol, and arelatively dominant progestogenic activity phase comprising threeconsecutive daily doses or an equivalent thereof, of a combination of asubstance exhibiting estrogenic activity equivalent to about 1 mg perday of 17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.
 8. The pharmaceuticalpackage as claimed in claim 7 containing a pharmaceutical regimen foradministration to a female in need of hormone replacement therapy, thedoses being arranged for administration in alternating phases, thephases consisting of a relatively dominant estrogenic activity phasecomprising three consecutive daily doses of a substance exhibitingestrogenic activity equivalent to about 1 mg per day of 17β-estradiol,and a relatively dominant progestogenic activity phase comprising threeconsecutive daily doses comprising a combination of a substanceexhibiting estrogenic activity equivalent to about 1 mg per day of17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.
 9. The pharmaceuticalpackage as claimed in claim 8 wherein the substance exhibitingprogestogenic activity is selected on the basis that it binds toprogestin receptors, it demonstrates poor affinity for androgenreceptors and has a lack of affinity for sex-hormone-binding globulin.10. The pharmaceutical package as claimed in claim 8 wherein thesubstance exhibiting estrogen activity is selected from17α-ethinylestradiol, esters and ethers of 17α-ethinylestradiol,17α-ethinylestradiol 3-dimethylamino propionate, 17α-ethinylestradiol3-cyclopentyl ether (quienestrol) and 17α-ethinylestradiol 3-methylether (mestranol); natural estrogens, estrone, estrone sulfate, estronesulfate piperazine salt, estradiol and estriol, and their esters, aswell as the synthetic estrogens, and the substance exhibitingprogestogenic activity is selected from desogestrel, dydrogesterone,medroxyprogesterone acetate, norethynodrel, cyproterone acetate,chlormadinone acetate, magestrol acetate, 17 D-acetyl norgestimate,dienogest, trimegestone, drosperinone and nomagestrel.
 11. Thepharmaceutical package as claimed in claim 7, wherein the doses are inoral form.
 12. The pharmaceutical package as claimed in claim 11,wherein the oral form is a tablet.
 13. A method of treating a female inneed of hormone replacement therapy comprising administering to saidfemale a pharmaceutical regimen comprising a plurality of doses arrangedin alternating phases, the phases comprising a relatively dominantestrogenic activity phase comprising three consecutive daily doses or anequivalent thereof, of a substance exhibiting estrogenic activityequivalent to about 1 mg per day of 17β-estradiol, and a relativelydominant progestogenic activity phase comprising three consecutive dailydoses or an equivalent thereof, of a combination of a substanceexhibiting estrogenic activity equivalent to about 1 mg per day of17β-estradiol and a substance exhibiting progestogenic activityequivalent to about 90 μg per day of norgestimate.
 14. A method oftreating a female in need of hormone replacement therapy as claimed inclaim 13 comprising administering to said female a pharmaceuticalregimen comprising a plurality of doses arranged in alternating phases,the phases comprising a relatively dominant estrogenic activity phasecomprising three daily doses of a substance exhibiting estrogenicactivity equivalent to about 1 mg per day of 17β-estradiol, and arelatively dominant progestogenic activity phase comprising three dailydoses of a combination of a substance exhibiting estrogenic activityequivalent to about 1 mg per day of 17β-estradiol and a substanceexhibiting progestogenic activity equivalent to about 90 μg per day ofnorgestimate.
 15. The method as claimed in claim 14 wherein thesubstance exhibiting progestogenic activity is selected on the basisthat it binds to progestogen receptors, demonstrates poor affinity forandrogen receptors and has a lack of affinity for sex-hormone-bindingglobulin.
 16. The method as claimed in claim 14 wherein the substanceexhibiting estrogenic activity is selected from 17α-ethinylestradiol,esters and ethers of 17α-ethinylestradiol, 17α-ethinylestradiol3-dimethyl amino propionate, 17α-ethinylestradiol 3-cyclopentyl ether(quienestrol) and 17α-ethinylestradiol 3-methyl ether (mestranol);natural estrogens, estrone, estrone sulfate, estrone sulfate piperazinesalt, estradiol and estriol, and their esters, as well as the syntheticestrogens, and the substance exhibiting progestogenic activity isselected from desogestrel, dydrogesterone, medroxyprogesterofle acetate,norethynodrel, cyproterone acetate, chlormadinone acetate, magestrolacetate, 17 D-acetyl norgestimate, dienogest, trimegestone, drosperinoneand nomagestrel.
 17. The method as claimed in claim 13 wherein the dosesare in oral form.
 18. The method as claimed in claim 17 wherein the oralform is a tablet.
 19. The preparation as claimed in claim 1 in which thedaily doses in the relatively dominant estrogenic activity phasecomprise about 1 mg per day of 17β-estradiol, and in the relativelydominant progestogenic activity phase comprise about 1 mg per day of17β-estradiol and about 90 μg per day of norgestimate.
 20. Thepreparation as claimed in claim 19, wherein the doses are in oral form.21. The preparation as claimed in claim 20 wherein the doses are intablet form.
 22. The package claimed in claim 7 in which the daily dosesin the relatively dominant estrogenic activity phase comprise about 1 mgper day of 17β-estradiol and in the relatively dominant progestogenicactivity phase comprise about 1 mg per day of 17β-estradiol and about 90μg per day of norgestimate.
 23. The package as claimed in claim 22,wherein the doses are in oral form.
 24. The package as claimed in claim23, wherein the doses are in tablet form.